My Specialty

Clinical Improvement Fellow Value Improvement Office, Robin Krasner, Keck Medical Center of USC

Evaluating processes to improve care delivery

Tell us about your nursing career.

My mother lost a battle with breast cancer at age 46. I had basically lived with her in the hospital for two months to serve as her advocate, so my aunt urged me to consider becoming a nurse.

My first nursing job was at a Veterans Administration hospital. After two years, I became a charge nurse, took a critical care training course and went on to work in cardiac critical care. I worked at a critical care medical ICU at a VA facility in Connecticut for 16 years. I also did various travel assignments, became a rapid response nurse at a Planetree facility and worked in general ICU in Texas for a few years.

My husband is from the Dominican Republic, so I also worked for a time as a consultant for a hospital in Santo Domingo, helping them prepare for Joint Commission International accreditation. It was a wonderful and challenging experience, since even the most basic things were not really standardized.

What is your current role at Keck Medical Center of USC?

Our Value Improvement Office started the clinical improvement fellowship in 2017. It’s an opportunity for a clinician to engage with administration in a unique way to bridge the gap between hospital leaders and frontline providers. It sounded very interesting, so I dove into the role in July 2018.

I spend two-thirds of my time as a clinical improvement fellow while maintaining one clinical shift per week. This allows me to continue engaging in direct patient care, maintain my clinical skills and bring what I’m learning back to my colleagues at the bedside.

I work mostly in the Care Delivery Redesign (CDR) pod. When I first started, it was all new to me. I didn’t know much about the business of healthcare, data transparency or the strategy and planning behind creating improvement and change, so it was challenging at the beginning.

Based on my clinical expertise and interests, I joined the Enhanced Recovery After Surgery (ERAS) project. Our seven-person, interprofessional ERAS team works to standardize care for surgical patients across clinical pathways, including pre-habilitation, optimal pre-surgery nutrition, multi-modal pain management, early mobilization and minimizing tubes and wires.

Overall, our goal is to help improve patient and family experience, encourage opioid-sparing techniques, decrease variation and reduce lengths of hospital stay.

How did you learn by observing the patient journey?

Some of our most valuable insights come through gemba kaizen, a Japanese methodology that stresses examining firsthand where the work takes places (the gemba) to look for opportunities for improvement (kaizen). This methodology came out of manufacturing [Editor’s note: It was first developed in the 1930s by Toyota!], but it can be used in many different industries.

By observing the patient journey, we discovered that only a small percentage of patients adhere to their pre-surgical instructions. We believe that this is not a matter of noncompliance, but rather of lack of consistency and quality of preoperative patient education.

Therefore, we concluded that we could have a profound impact on our goals by improving standardized patient education. If patients are well-prepared and clearly understand what we expect of them — and they of us — they can better drive their own care.

How does technology figure into increasing patient engagement and quality of care?

Technology can reduce variations in processes, which helps to ensure that more patients benefit from the improvements we implement. It also helps with data collection. For example, we’re creating a digital dashboard that uses EHR data to monitor adherence and track outcomes. However, it takes time, effort and resources to put all the tech puzzle pieces in place.

We have developed provider order sets and migrated them to the EHR, but each set requires a rigorous approvals process through various hospital committees. Once a process is in the EHR, providers can use the order sets and personalize them for each patient.

Do you find providers resistant to change? Where does that resistance happen?

It happens just about everywhere. While we have some ERAS early adopters who are open to trusting the process and evaluating the results, others can be hesitant to embrace this major change in how we operate. However, once they see the results and how great patients look post-operatively, the skeptics realize how well it works.

It can be hard to get nurses on board with changes like early postoperative mobilization because they may see it as another time-consuming task that nurses must coordinate amongst all the other tasks to be completed during a shift.

Hiring Now

Do you often hear that old nursing adage, “That’s the way it’s always been done”?

We frequently encounter fear of change from staff (e.g., “But, we’ve always given morphine!”). We address it through a lot of actual face-to-face engagement with the nurses; it’s a continuous dialogue.  Our team rounds, talks to patients, shares evidence and best practices, gives feedback and addresses commonly held concerns. We hold monthly feedback forums for staff whose work brings them into contact with ERAS patients so that we can share data and discuss what’s going well and what could be better. (Good snacks help, too!)

Is there a success story you’d like to share?

To evaluate how one service line delivers their care, we went to a preoperative patient meeting for spinal surgery. We sat through the patient’s appointment and listened intently. We also shared information and educated the patient and her daughter about what to expect. I speak Spanish, so I was also able to communicate with the patient in her own language, which built a powerful bridge of trust.

One day after her surgery, while she was in the ICU, we went to visit her. We helped the patient sit up and eat breakfast, and we received a great deal of positive feedback from her and her family. That was very gratifying.  I also experience great joy when colleagues see me in the hallway and thank me for helping with their patients. They say things like, “My patient is getting up and around, isn’t taking narcotics and and around, isn’t taking narcotics and feels great!”

What are your hopes and aspirations for your career?

This fellowship lasts 18 months, and I look forward to every day I serve in this role. I’m so grateful to have so many different opportunities. For example, our team submitted an abstract to the 7th ERAS World Conference in Liverpool, England. It was the first time I had ever attended a conference, and I had the opportunity to deliver the oral presentation on behalf of our team. It was a fantastic experience.

I’m currently enrolled in an FNP program at USC. After completion, I plan to do a post-master’s certificate in acute care. I also love the idea of engaging more deeply in telemedicine, perhaps for when I want to retire and work from my home in the Dominican Republic!

I feel so blessed to have found my calling — I love being a nurse. Nurses are amazing individuals, and we do our best work when we’re involved in multidisciplinary teams that also include patients and their families.

That is how I know our ERAS program will grow in popularity, overall reach and success.  Ultimately, we aspire to continuously improve the ways we keep patients and their families informed and engaged, thus improving their outcomes and overall health. What could be better than that?


Keith Carlson, RN, BSN, CPC, NC-BC, has worked as a nurse since 1996 and has maintained the popular nursing blog Digital Doorway since 2005. He offers expert professional coaching for nurses and nursing students at www.nursekeith.com.


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